Shock
These are manifestations seen in shock
What are low BP, tachycardia (except in neurogenic shock), hypoxemia, MAP below 65 mm Hg, dysrhythmias, liver and GI function decline, decreased LOC, increased cap refill time, decreased urine output, etc....
These are signs of inhalation injury
What are carbonaceous/sooty sputum, smoky smell to the breath, singed nose and facial hair, hoarseness, wheezing, drooling, difficulty swallowing, stridor
These are interventions following a snake bite
What is lay the client down, remove constricting items, clean the wound and cover it, immobilize the area, place in a dependent position
This is the main reason we use decontamination protocols following exposure to specific agents
Care for suicidal client
Inspect belongings, ask about a plan, no metal utensils (plastic), no cords, no client gown with ties. 1:1 sitter...etc
These are the steps of the 1-hr Sepsis Bundle
What are measure lactate, obtain blood cultures; administer broad-spectrum antibiotics; begin rapid administration of crystalloid 30 mL/kg; Start vasopressors if needed
This is the TBSA of a client who sustained burns to the anterior torso and front of right leg
What is 27%
This is the treatment for a client exposed to inhalation anthrax (respiratory/flu-like symptoms)
What is administer ciprofloxacin (or other effective antibiotic). Flu like symptoms, however, it's bacterial infection!
This is the priority treatment of a client exposed to carbon monoxide
What is remove the client from the area of CO and administer oxygen at 100%
Carbon monoxide is tasteless, odorless, and colorless
Symptoms and Treatment of anaphylactic reaction
Symptoms-high RR and HR, low BP and pulse Ox, difficulty breathing/swallowing, hives. Give epi, O2, IV fluids, antihistamine/steroids (if needed), document reaction.
Symptoms and treatment for hypovolemic shock (bleeding out vs. fluid loss due to dehydration)
Low BP, tachycardia, high RR, high temp, decreased LOC, distended abdomen, low H&H - (if internal bleed). Treatment: ABCs - O2, fluids and vasopressors if needed, apply pressure if active arterial bleed, electrolytes (K), monitoring I&O, vitals, cardiac monitor....etc.
These are the priority treatments of clients with burn injuries
What is establish an airway and start IV fluid resuscitation. Order depends on airway involvement.
These are interventions for a client exposed to sarin gas and other nerve agents
What are seizure precautions, supportive care, meds, decontaminate with soap and water or saline for at least 20 minutes. Do not use plastic airway devices
When delegating, consider these:
Follow the Nurse Practice Act (for LPNs), consider their knowledge and skills to perform the task before delegating
Care for frostbite
What is re-warming with warm water (not dry heat to avoid burns), elevating extremity to prevent compartment syndrome
This medication is administered to a client in shock to increase MAP and cardiac output in addition to fluids
What is norepinephrine (Levophed) first
These are signs that fluid resuscitation has been effective
Increased BP, decreased HR, increased Urine output
Priority findings: ABCs and comparing vital signs
Pick top 3 priorities:
RR 24
pulse ox 94-95%
HR 118 bpm
BP 100/60 mmHg
GCS = 7
Who to triage first?
Pick top 2:
Client who is agonal
Client who has 90% burns on the body
Client who burns to upper torso
Client who has tension pneumothorax
Care for sexual assault victim
SANE nurse assessment, obtain history of the incident, don't ask to repeat the information, go as fast as client needs to go, no wiping down or showering prior to exam, photos not always required
These are nursing interventions to implement to prevent neurogenic shock from occurring
What are immobilize the spine if spinal cord injury and elevate HOB if client received spinal anesthesia
What complications are burn clients at risk for?
Fluid overload, infection, compartment syndrome, electrolyte imbalances (Na, K, H&H), nutritional deficiencies, PTSD, recovery complications...etc.
Alcohol withdrawal symptoms
Increased HR, anxiety, hallucinations, sweating, headache, light sensitivity, delirium, LOC changes...etc.
A client is assessed following a mass casualty incident and presents with a broken arm. Radial pulses are present and cap refill is <3 secs. What color tag should this client receive?
What is green
Manifestations of heat exhaustion
Dehydration, elevated temp, confusion, hypernatremia